MEDICARE: DR. THEODORE P. LOGAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	012617	ME
2	2084P0800X	Psychiatry Physician	MD12617	ME
3	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	MD12617	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	047853	OTHER	ME	ANTHEM STAR NUMBER

General Provider Information

NPI Number	:	1427054873
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THEODORE P. LOGAN MD

Provider Business Mailing Address
First Line	:	300 SOUTHBOROUGH DR
Second Line	:	SUITE 201
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-6914
Country	:	US
Telephone Number	:	207-661-2018
Fax Number	:	207-661-2033

Provider Business Practice Location Address
First Line	:	12 UNION ST
Second Line	:
City	:	ROCKLAND
State	:	ME
Zip	:	04841-2739
Country	:	US
Telephone Number	:	207-701-4400
Fax Number	:	207-701-4487

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	03/21/2017

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